MEDICARE: LIGHT BRIDGE COUNSELING GROUP LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1770446312
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIGHT BRIDGE COUNSELING GROUP LLC

Provider Business Mailing Address
First Line	:	3238 NW 47TH AVE
Second Line	:
City	:	COCONUT CREEK
State	:	FL
Zip	:	33063-1800
Country	:	US
Telephone Number	:	954-205-6773
Fax Number	:

Provider Business Practice Location Address
First Line	:	3238 NW 47TH AVE
Second Line	:
City	:	COCONUT CREEK
State	:	FL
Zip	:	33063-1800
Country	:	US
Telephone Number	:	954-205-6773
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	GAVIN VANDERWAL MALCOLM
Credential	:	LCSW
Telephone Number	:	954-205-6773

Provider Enumeration Date	:	12/09/2025
Last Update Date	:	12/09/2025

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